FIELD METHODS FOR COMMUNITY HEALTH REPORT 2006 THE PRECPTIONS OF WASTE WATER AS AN ISSUE OF PUBLIC HEALTH IMPORTANCE IN THE MONTEVERDE ZONE COSTA RICA Scott Baker J anelle Elliot Desirae Nasrallah Kenn a Noone Kirkpatrick Faculty Advisors: Dr.Nancy Romero Daza, Dr. David Himmelgreen Field Methods for Community Health Monteverde Institute June 18 to July 23, 2006

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1 Team Background Kenna Noone Kirkpat rick is a Professor of Anthropology in the Department of Social Science at Seminole Community College. She also is on the faculty of Psychology at the University of Central Florida where she teaches Cross Cultural Psychology. Her work for the last 14 years has focused on community issues in the Maya communities in the state of Quintana Roo, Mexico. Her Spanish is somewhere between intermediate and advanced. Desirae Nasrallah B.S. in microbiology and cell science, is currently a candidate for a Masters of Public Health, in Global Health and Epidemiology from the University of South Florida. She speaks intermediate Spanish and has worked in Latin America on various sustainable health projects. Scott Baker is a senior undergraduate student of Biology and Ant hropology at California State University at Sacramento and performs research on antibiotic resistant intestinal bacteria. He speaks basic Spanish. Janelle Elliott University of South Florida, seni or undergraduate, Anthropology. She speaks S panish at th e intermediate level. Introduction democracy. It has the best educational system resulting in a nation with one of the highest literacy rates in the Western Hemispher e. It is known for its social security system that is

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2 dedicated to universal health care. It is also a nation rich in n atural beauty with a strong eco source of income after silicon chip production, (Dulude, 2000.) Water treatment, specifically that of waste water management, is not handled well Costa Rica. The nation has one of the worst records for waste water management in Central America. Mora (2003) reported that Costa Rica delivers treated water to 97.4 % of its citizens, with 76% of Costa R icans receiving 100% potable water from their house faucets. As good a record Costa Rica has for delivering potable water to their citizens the opposite is true of their record for waste water treatment. Mora (2003) study went on to report that while 98% of the households had some sort of system to handle waste waters, most of the systems were merely septic tanks or, in the case of 77% of its citizens, a a deep hole in the ground. Nicaragua, a new and struggling democracy with a much lower literacy rate and with a weak health delivery system, treats 34% of its grey waters while Costa Rica treats a mere 4% of its grey waters (Cambrano, et.al., 2003). How is it, in a nation that historically emphasized health and education and is currently aggressively presenting itself for tourists as ecologically aware have such a poor record something as environmentally damaging as untreated waste waters ? How does th is lack of treatment affect the environment and public health? What perceptions do citizens have about the relationship between waste waters, health and the environment ?

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3 The Monteverde Z one includes the communities of Santa Elena, Cerro Plano, Caitas a nd Monteverde. It has been very successfu l in marketing itself as an eco tourist area. This has resulted in a recent rapid growth in population. Any increase in population, regardless of individual roles as permanent resident or tourists, impact the natura l environment, puts pressures on the existing infrastructure and increases the demand for services. This zone reflects many of the tensions that exist in the nation at large. Certainly the re exists a potential of the ecotourism industry to become ecolog ically damaging as it deliver s employment and income to Costa Ricans, as well as adventure and knowledge to tourists There is diligence in providing potable water to households that is in contrast to the lack of sound waste water management. The marketi ng of the Monteverde Z one as being protective of the natural environment and eco friendly is in conflict with the practice of allowing waste waters to run into the streets, fields, and small streams. The question arises as to what are the ramifications of unmonitored waste wate r on health. In the Monteverde Z one, it is apparent that acc ess to health care is universal, a nd the community can be lauded for regularly monitoring the health of school aged children. This is in contrast with the risk children face from the possible and relatively easy contact with waste wate rs. Finally, in the Monteverde Z one, the investigators of this study were also curious about consistent comments from the community of the regular t reatment with anti parasitic medications Thi s also conflicts with the tacit acceptance of a source of parasitic infection in the form of untreated waste waters.

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4 goes down significantly, but the role of parasites is more important. Fewtrell, et. a l (2001) in discussing the assessment of risk for water related diseases, stated that when waste waters are treated, and agricultural contamination from black wate rs are reduced that intestinal nematodes decrease. This seems particularly pertinent to t he situation in the Monteverde Z one. Purpose It is the purpose of the present study to explore the perceptions of the waste water as an issue of public health impo rtance due to sanitation and infrastructure in the Monteverde zone, Costa Rica, C.A. S pecific research objectives include d : Assess ing the knowledge of community members about waste water Assess ing the knowledge of community members about waste water t reatment/containment in their area Assess ing the knowledge of community members about parasitic infections Assessing the community perspective on the connectio n between contaminated water, health and the environment Method s This study employed both qua litative and quantitative methods. These methods included observations, collection of archival data, interviews, focus groups and surveys. Observations of the Monteverde Z one were documented. Several of these observatio ns were photographed (Appendix 10 ) The observations were made in the downtown area of

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5 Santa Elena to become familiar wit h the mix of businesses in the area The seat of the municipal government of Santa Elena, the local office of AYA, as well as the local EBAIS clinic ( Social Security heal th clinic) were visited in order to examine specific public records and documents. The Granaje Porcina a local pig farm, was also visited in order to observe their water treatment and water run off process Two surveys were taken. The first survey (N=22 ) was given to adults who participated in a health fair held in a small farming community close to Santa Elena (Appendix 2 ) The second survey ( N= 38 ) was given to adults working in the Santa Elena business district, employees and clients of the Montever de Clinic and employees of the M onteverde Institute (Appendix 3 ) The data for both surveys were entered into SPSS Version 14, for quantitative analysis and examined for qualitative information. A focus group of local area women was held N= 4 (A ppendix 4) Five interviews were held. Partici pants included local politician private laboratory physician and municipal water professionals. All interviewees were people who worked in water management in some professional capacity (Appendix 5). Results In th e Monteverde Zone 63.6% of participating subjects reported using anti parasit ic medications ( e.g. Zentel, alb endazole). See Appendix 6, Figure 1. Possible s ources of parasitic infections w as divided into eight choices sweat, bad weather, junk food, uri ne, food, fecal matter, dirt, and not washing your hands (Appendix 6, Figure 2). Of the above

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6 choices, 4.2% of respondents believed sweat was a source of parasitic infection, 8.3% believed bad weather to be a source, 16.7% reported junk food as a source, 1 6.7 % chose urine 37.5% reported food as a possible source, 50.0% chose fecal matter, 58.3% chose dirt, and 91,7% of all respondents chose not washing your hands a possible source parasitic infections. Subjects were also asked where they learned abo ut causes a nd treatments for parasites (Appendix 6, Figure 2). Twelve point five percent reported learning about parasites from doctors and/or clinics, 12.5% reported having learned from multiple sources and another 12.5 % reported not knowing /not remembe ring where they learned. Another 16.7% reported having taught themselves about parasites 20.8% learned from schools and 25% learned about parasites from charlas which are educational talks Approximately 97.4% of participants report ed owning a septic tank (Appendix 6, Figure 3). People who understood how a septic tank functioned were more likely to service and maintain their septic tank (Appendix 6, Figure 4). Approximately 60% of subjects report that black water flowed into their septic tank (Append ix6, Figure 5). Also, 15.7% reported black waters flow to a septic tank followed by a drain field, 9.8% did not know where the bl ack waters went, 5.9% reported black water flowed to a drain field alone, 3.9% reported the black water flowed directly outside 2.0% reported flow into a drain and 2.0% reported that their black water flowed directly into the street. When asked where their grey water flows after use, 23.3% reported to a drain field, 20.0% said directly outside, 20% reported it flowed directly to the street, 13.3 % said to a septic tank, 6.7 % to a septic tank with a drain field, 6.7 % did not know, 6.7 % said to a drain and 3.3% reported that their grey water flowed to the river (Appendix 6, Figure 6).

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7 Almost all of the people surveyed (93.8%) agr businesses allowed their grey waters to flow directly int o the streets (Appendix 6, Figure 7). The subjects were asked to report their top three choices regarding maintaining per sonal hygiene (Appendix 6, Figure 8). Cho ices included washing your hands (26.2%), other hygiene practices (21.5%), being careful with water (10.8%), brushing your teeth (10.8%), taking out the trash (10.8%), eating health food (7.7%), cleaning the house (6.25), and cleaning t he bathroom (3.1%) all of the above ( 3.1%). All subjects were asked whether or not a waste water treatment plant was needed in the Mo nteverde Zone (Appendix 6, Figure 9). Of those who answered, 90.6% thought that it tant but other issues are more waters on the health of the community, almost all responses were similar. Some were mor e articulate than others. There was a saturation of similar responses from all of the instruments employed The following are some selected quotes : ause now most of the houses and businesses let everything go into the rivers and streets and it is very disagreeable. There are a lot of problems and it also produces a lot of mosquitoes and other bugs. I believe our fault; in the future we will have

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8 most important problem in Montev erde because of tourism and business. We are contaminated now and we will be more The following comes from a n interview with a professional who works with water in the Monteverde Zone: Contamination is becoming a large p roblem. Getting out of control. No one checks this contamination, but everyone knows it is happening. If contamination their grey waters out front (instead of behind) their businesses so that people can choose whether or not they want to go into that establishment. Businesses The following q uotes come from the community. These ideas summarize the a ttitude in regard to p erception of p arasites : aste water] contaminates the water sources, proliferat ion of parasites, outbreaks of d Everyone [is su

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9 [Eliminate parasites] with preventive medication, washing the hands abundantly [Eliminate parasites by] t Conclusions A definite contradiction occurs within the Monteverde zone concerning its treatment of water. While the citizens receive 100% potable water, there is no organized system of wastewater managem ent. The purpose of this study was to explore perceptions of wastewater as an issue of public health importance in the Monteverde zone. Two issues were examined: how the community perceived the relationship between wastewaters and health and whether or no t the community perceived waste waters as a threat. In an interview, a key informant advised the study group that there was an increase in parasites within the last few years in the local creeks and rivers. Further, the informant reported an increase in pe ople who presented themselves with parasitic infections. The study group also encountered many community members who reported taking anti parasitic medications some on a regular basis Our observations are in agreement with finding in 2002 that as a community is able to deliver clean drinking water, the amount of infectious bacteria decline, but the importance of parasitic infections rises. data both qualita tive and quantitative that indicated that correspondents had sound basic knowledge about how wastewaters were and were not treated in their community. They

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10 almost universally agreed that it was a very important issue and posed a threat to their community Data also sugges ted that, for the most part, community had a sound basic knowledge of the diagnostics, prevention, and treatment of parasitic infections. They are well aware of the relationship between contaminated water, health and the environment. Wh at is unfortunately present is a seeming tacit agreement to accept the untreated waste water. One question people were asked concerned how one could eliminate parasites. Most correspondents mentioned something that was individualistic in nature. Not one pe rson mentioned doing something about waste waters to aid in the elimination of parasites. The conclusion of this study is that only collected community action will solve this problem. In order to initiate the process of building a waste water treatment p lant, the community will need to demand action from the municipality. The existence of the ability to meet the demands of its rapidly growing population in a way that preserv es the health of its residents and protects the environment. Recommendations for Future Studies There are several pos sibilities for future studies. There is some evidence that a large portion of the community regularly treat, self treat or by doctor cons ultation, for parasitic infections. In the repo rted sta tistics provided by the EBAIS Situation Analysis from 2004 and 2005, it is not clear whether parasitic infections comprise a significant cause of morbidity. There is a discrepancy between the availabl e data and the behavior exhibited by the community. It would be of interest to explore the hygiene and sanitation practices

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11 in the individuals in the community to assess whether, or not the community apply the knowledge they posses. According to data collected in this study, 97.4% of people surveyed owned septic tanks. Since such a large portion of the community use septic tanks to control black water in the community, it would be of interest to know 1) what kind of septic system is installed in the a rea, 2) if the tanks were properly installed, 3 ) if the tanks are pr operly maintained and 4 ) if septic tanks in the community are a sufficient means to protect this rapidly growing community. There is a heated debate currently occurring about water righ ts in the Monteverde Zone. Water evokes an extremely socially and political ly charged argument among many members in the community. Monteverde is already at capacity in regards to new water connections for new residents and businesses moving into the area The area currently experiences frequent water service interruptions. This formerly occurred only in the dry months, but has now begun to occur in the rainy season, as well. The issue at hand is how to best regulate businesses, especially hotels, and th e rapid growth in order to protect the precious water sources and, therefore, the population s health in the Monteverde Zone. Study Limitations Language barriers have been a common difficulty throughout the course of the project. With only one advanced Spanish speaker, it was a challenge to preserve the richness and

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12 accuracy of the data acquired. This was most evident during the focus group. More subjects could have been recruited for interviews, survey questionnaires and focus groups had there not bee n such a strong time constraint. The survey sample size was small, but the data collected has been quite useful The sample could have been more diverse by including more men, business owners and hotel owners. In retrospect, during data analysis from th e survey instrument it was noted that a few questions would have useful had they been included. Finally, t he statistical software, SPSS, occasionally lost lines of data. Frequent review of the data was necessary in order to ensure that data was correctly represented in the analysis. Although care was taken, it is possible that some data may be incorrectly reported due to a flaw in the software.

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13 Acknowledgements The water and health research team would like to thank the following people for their contri butions to our research, because without them we could not have carried out our project..... Our community advisor Dr. Alfonso Calvo Artavia MQC., for all his wisdom and guidance, we w ould have been lost without him Our professors David Himmelgreen Ph.D., M.A., Nancy Romero Daza Ph.D.,M.A., and Linda Whiteford, Ph.D.,MPH., for their knowledge on conducting research and their constant guidance Our program coordinator Jenny Pena, for coordinating logistics and making our stay very convenient Employees from Ay A, for giving us information on the water systems of Costa Rica The personnel at the Monteverde Clinic, particularly Dr. David Castillo for allowing us to conduct research at the clinic The community members that participated in our interviews, focus group and our su rveys, we could not have carried out our research with out their input The graduate mentors, Scott Mitchell and Federico Cintrn Moscoso, for h elping us through our endeavors And of course the residents of Monteverde for welcoming us into the c ommunity, being so open and helpful and participating in our research It is to the community that this study is dedicated

22 Appendix 5 Interview Topics Explain t he nature of your work with AyA Ask about quality of water in this area. How is the water quality assessed? How often is that quality assessed? Ask abou t quality/quantity of water in this area Service interruptions? If so why. Explore possible patterns, time of year, location, and AyA awareness. How do people access water during these interruptions? After an interruption, how is water quality rea ssessed. What kind s of microo rganisms are found in the water? How is AyA dealing with the growth of the community in this service area? Is the system stressed? How does AyA handle gre y waters? What other water delivery systems exist in the Monteverde Zo ne? Adv ice on possible research topics